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Q & A Medical 02/03

Dr Ian Sibley-Calder has been a GP since 1988, is a medical referee for the UK Sports Diving Committee and is involved with hyperbaric medicine and commercial diving activities. He is a BSAC Advanced Diver and Club Instructor.

A patient undergoes echo-cardiography, an ultrasound test of the heart. The operator holds a transducer to his chest to produce an image of the heart chambers and valves on screen

CAN I BE TESTED FOR A HOLE IN THE HEARTI would like to move to decompression diving over the coming year and want to take a PFO test to make sure I dont shunt bubbles and bend myself. Could you give me any details about costs, waiting lists, places to have it done etc

PFO (patent foramen ovale) testing is not easy. The area of the heart that is looked at is almost lying against the backbone, so the scan or echocardiogram has to be done looking at the heart from the gullet. The diver has to swallow a probe under sedation until the atrial septum can be seen. A defect/flap in this area is what is looked for. Some agitated water (with bubbles in) is injected into the diver and the scan looks for any bubbles crossing abnormally from the right to the left side of the heart. This is also done with the diver performing a valsalva. For a diver, the test would have to be done privately and would cost around£400. It is best performed by a consultant knowledgeable in diving medicine. There is then a problem with interpretation. Small PFOs are probably not significant and only those greater than 10mm are thought to increase risk of decompression illness. This is not exact and work is still ongoing to find the exact relationship between PFOs, their size and DCI. If you had a PFO, would it stop you diving, limit your diving or would you ignore it In general, PFOs are probably not worth looking for until after a problem has developed and the test is recommended by a doctor trained in diving medicine. This will be the case at least until we have more knowledge of how much they increase the risk in a well diver.

I am epileptic: can I diveI would like to take up diving, but I suffer from epilepsy. I have been diving once on holiday and I was fine. I am on Epilim 500 and Tegretol Retard, which I take morning and evening, and have had no fits for the past three years or so. Do you think I would be OK to pass a Diving Medical S

Sorry, no diving while on epileptic medication. Epilepsy is one of the major contra-indications to diving and a fit under water equals death. There is also the issue of side-effects of the medication used to control the epilepsy, which can cause reduction of reflexes and drowsiness on the surface, let alone under hyperbaric pressure. We do not allow people to dive unless they have been fit-free and off all medication for three years.

Taking the plunge with new kneesI am due to have an operation to renew both my knee joints. I am a fit 67-year-old who dives regularly abroad and in the UK. Do you foresee any problems in my continuing to dive once I have the all-clear from the surgeon John

This is not always an uncomplicated operation and patients can suffer from residual pain, deformity, infection etc. Provided everything goes all right and you are fully recovered I cannot see a major problem with you diving, though you may have to adapt in terms of severity of dive, fin strokes, types of fins and so on.

Swelling in the neckI noticed a soft swelling on the left side of my neck about five weeks ago and it seems to have got larger. It disappears when pressed in and causes no pain. My GP, who knows nothing about diving, examined me thoroughly and asked me to breathe in, seal my mouth and breathe out while he studied the blood flow. The swelling enlarged and went red. He has contacted a vascular specialist to get a scan done but I need to know if it will be safe for me to dive. Could the pressure of my drysuit neck-seal be a hazard Steve

What I suspect your GP is worried about is an aneurysm - an abnormal swelling on one of your blood vessels. While I think it unlikely that you would have a problem, it may be prudent to avoid diving until the scan confirms whether there is anything to cause concern. If this does turn out to be something more serious, I would suggest that you contact your nearest doctor interested in diving medicine with as many details as possible.

Returning after a heart attackLast year I suffered a heart attack - not a major one, but inferolateral, as the doctor described it. I was in hospital for the minimum five days. I was placed under various temporary restrictions on driving and flying but when I asked about diving I was told I should not dive any more. My instructor, a former nurse, told me I should wait for a year then have a medical and see how that turns out. Do you agree Hugh

Diving after heart attacks depends on assessing the individual. Heart problems are thought to be a common cause of medical deaths under water. In general, patients must have had little heart damage, show good heart function and no evidence of angina/ ischemia, and be off all cardiac medication (though lipid-lowering drugs and anti-platelet agents are permitted). They must have had an electrocardiogram that shows that they are capable of undertaking a good amount of exercise without the heart showing any signs of strain. Even when considered fit to dive, such people should dive only with experienced buddies able to render assistance if necessary. They must be reviewed annually or in the event of any change in their medical condition.

My left ear wont co-operateI have recently started diving and have a problem equalising. The right ear clears very quickly but the left does not. This weekend after surfacing I had a nose bleed from trying to force the equalisation so that I could get down. Do you think I may have some sort of blockage on my left side, as it feels and behaves very differently to my right! Tim

Wax can be a problem for divers who have problems equalising in one or both ears, and syringing is a simple way of dealing with it

It is not unusual for new divers to have problems clearing their ears, and one ear is often stickier than the other. In most situations it is just the valve at the entrance to the Eustachian tube (which connects the back of the throat to the middle ear, allowing equalisation of pressure) that does not open well. With time and practice this becomes floppier and easier to open. No diver should force equalisation hard enough to cause the damage you describe. It is potentially dangerous, and doesnt work. Get your ears and nose checked by a doctor, preferably one interested in diving medicine. Wax can be a problem but it is also worth checking the septum in the nose (the bony bit in the middle) to see that air flow is normal and not obstructed. Severe deformities can sometimes need correcting before diving can take place. After that, it is a matter of technique, time and patience. Make sure that you try to equalise frequently and before pressure is felt in the ears. By then, the pressure difference is sometimes so great that the eardrum becomes splinted and unable to equalise. If unable to equalise, ascend to relieve pressure and try again. Many novices take a lot of time to descend and need a patient buddy. Dont rush it.

Asthma and divingI am interested in diving, but have been told that I cannot take part because I suffer from asthma which is controlled by Seretide. Is it the medication I am taking that prevents me from diving, or is it that I have asthma Natalie

Asthma is considered a risk factor in diving because closure of the airways can lead to air-trapping. On ascent this can increase the risk of pneumothorax (popped lung) and CAGE (cerebral arterial gas embolism). Over the years, under the guidance of the UK Sport Diving Medical Council, there has been considerable relaxation of the rule that no asthmatic should dive in this country. Divers should not need to take regular relievers (blue) but are allowed to be on preventors (brown or orange). Their lung function needs to be carefully assessed by a diving doctor using specialist tests, both before and after significant exercise. If there is no reduction of function they may be able to do some diving under restrictions. Seretide is a treatment combining two drugs: a preventor (like the orange type) and a long-acting reliever. As we have even less experience of these drugs and diving, at the moment they cannot be recommended. The situation may change as more is found out. Some countries still do not allow any asthmatic to dive, even under the UKs strict guidelines.